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Why We Did the Study
Research has shown that children who lack
access to health care are more likely to be in
poorer health ( CDF, 1997). One Smart Start
effort to improve children’s health is to improve
access to health care. Head Start, a center- based
program for preschoolers that includes a health
component, has been shown to improve a
family’s use of preventive and curative health
care ( Zigler & Valentine, 1979). Head Start also
has been shown to identify children with
asthma earlier, resulting in more timely
treatment and preventing hospitalization and
repeated use of expensive medical services
( McGill et al., 1998). Because Smart Start also
seeks to improve children’s health, this study
addressed the question, “ Are children from
Smart Start- supported child care centers
more likely to have a regular source of
health care than other children?”
Smart Start Quality Improvement
Services for Child Care Centers
Approximately 189,000 children, or 30% of
all North Carolina children under age 6, are
enrolled in licensed, center- based care in North
Carolina ( Division of Child Development, 1998).
To reach many of these children, at least three-fourths
of Smart Start funds ( averaged across
all counties) are being spent on child care
access or quality improvement activities.
The quality improvement activities include:
• On- site technical assistance ( e. g., a consult-ant
visits the center and provides center-specific
or classroom- specific suggestions
for improving the quality of care)
• Programs to increase the education and
knowledge of early childhood teachers
• Special enrichment activities for children
• Workshops and CPR trainings for teachers
• Grants to centers to improve their facilities.
How We Conducted the Study
The Evaluation Team identified seven diverse Smart
Start partnerships that were supporting several child
care quality improvement efforts ( FPG- UNC, 1999).
Six of these agreed to participate in a study of kin-dergarten
entry skills. The FPG Evaluation Team and
local partnership staff identified child care centers
that had participated in most of the Smart Start
quality improvement activities offered by their part-nerships.
The staff at those child care centers then
helped recruit all children who would be attending
kindergarten in the fall. When these children
entered kindergarten, their teachers helped recruit
a comparison group of children who had attended
a non- Smart Start child care center. All children in
both groups had at least eight months’ experience
in child care. There were 213 children in the Smart
Start group and 290 in the non- Smart Start group.
For this KHA pilot study we collected data from
each child’s Kindergarten Health Assessment ( KHA)
form. In North Carolina every child entering kinder-garten
must submit a KHA to the school. With the
consent of the parents, trained data collectors read
the KHA form and coded parents’ responses to the
question about where the children received regular
health care. For analysis, we combined the categor-ies
for private doctor, HMO, public health depart-ment
and community health center into the
“ Regular Care” category. Similarly, we combined
the categories for emergency room, hospital clinic,
none and other into the “ No Regular Care” cate-gory.
Although it was not possible to know in
every case what “ other” was, we included it in
the “ No Regular Care” category because it was
not one of the sources of care usually considered
to be “ regular,” namely, a doctor’s office, an HMO,
etc., where one would see the same provider again
and again. Finally, to account for possible effects of
family income or ethnicity on having a regular
source of health care, we entered these variables
in the analyses. We used eligibility for free or
reduced price school lunches to identify children
who were poor.
What We Found
The kindergarteners from child care centers
who had participated in Smart Start quality
improvement activities were significantly
more likely to have a regular source of
health care than children who had not.
Ninety percent ( 90%) of Smart Start
children had a regular source of health
care compared with 82% of non- Smart
Start children. Conversely, 18% of
non- Smart Start children had no
source of regular care compared
to 10% of Smart Start children.
The positive effect of Smart Start child care
on having a regular health care provider
did not differ between white and African
American preschoolers, or between poor
and non- poor children.
Implications and Future Directions
The results show that increased access to regular health care
for children is associated with attendance at child care centers
that participate in Smart Start quality improvement activities.
These activities were not intended directly to affect access to
health services, but it appears that they did or that they are
associated with activities that we did not measure that have an
effect on health services. However it is achieved, any reduction in
use of emergency room care represents a significant cost savings.
Typically, an emergency room visit for a Medicaid- eligible child
with acute otitis media costs $ 41.50, compared with $ 35.52
for an office visit. 1
These preliminary findings of regular access to health care for
children attending centers involved in Smart Start are encouraging.
We are currently completing a larger study focused specifically on
children who participated in Smart Start health interventions.
With more children from more counties, we will be able to assess
the effect of Smart Start on immunizations and other measures
of health status outcomes in addition to access to care.
1 Personal Communication, P. Munson ( Division of Medical Assistance) and S. Horton
( Division of Public Health), NCDHHS, Sept. 15, 2000.

Why We Did the Study
Research has shown that children who lack
access to health care are more likely to be in
poorer health ( CDF, 1997). One Smart Start
effort to improve children’s health is to improve
access to health care. Head Start, a center- based
program for preschoolers that includes a health
component, has been shown to improve a
family’s use of preventive and curative health
care ( Zigler & Valentine, 1979). Head Start also
has been shown to identify children with
asthma earlier, resulting in more timely
treatment and preventing hospitalization and
repeated use of expensive medical services
( McGill et al., 1998). Because Smart Start also
seeks to improve children’s health, this study
addressed the question, “ Are children from
Smart Start- supported child care centers
more likely to have a regular source of
health care than other children?”
Smart Start Quality Improvement
Services for Child Care Centers
Approximately 189,000 children, or 30% of
all North Carolina children under age 6, are
enrolled in licensed, center- based care in North
Carolina ( Division of Child Development, 1998).
To reach many of these children, at least three-fourths
of Smart Start funds ( averaged across
all counties) are being spent on child care
access or quality improvement activities.
The quality improvement activities include:
• On- site technical assistance ( e. g., a consult-ant
visits the center and provides center-specific
or classroom- specific suggestions
for improving the quality of care)
• Programs to increase the education and
knowledge of early childhood teachers
• Special enrichment activities for children
• Workshops and CPR trainings for teachers
• Grants to centers to improve their facilities.
How We Conducted the Study
The Evaluation Team identified seven diverse Smart
Start partnerships that were supporting several child
care quality improvement efforts ( FPG- UNC, 1999).
Six of these agreed to participate in a study of kin-dergarten
entry skills. The FPG Evaluation Team and
local partnership staff identified child care centers
that had participated in most of the Smart Start
quality improvement activities offered by their part-nerships.
The staff at those child care centers then
helped recruit all children who would be attending
kindergarten in the fall. When these children
entered kindergarten, their teachers helped recruit
a comparison group of children who had attended
a non- Smart Start child care center. All children in
both groups had at least eight months’ experience
in child care. There were 213 children in the Smart
Start group and 290 in the non- Smart Start group.
For this KHA pilot study we collected data from
each child’s Kindergarten Health Assessment ( KHA)
form. In North Carolina every child entering kinder-garten
must submit a KHA to the school. With the
consent of the parents, trained data collectors read
the KHA form and coded parents’ responses to the
question about where the children received regular
health care. For analysis, we combined the categor-ies
for private doctor, HMO, public health depart-ment
and community health center into the
“ Regular Care” category. Similarly, we combined
the categories for emergency room, hospital clinic,
none and other into the “ No Regular Care” cate-gory.
Although it was not possible to know in
every case what “ other” was, we included it in
the “ No Regular Care” category because it was
not one of the sources of care usually considered
to be “ regular,” namely, a doctor’s office, an HMO,
etc., where one would see the same provider again
and again. Finally, to account for possible effects of
family income or ethnicity on having a regular
source of health care, we entered these variables
in the analyses. We used eligibility for free or
reduced price school lunches to identify children
who were poor.
What We Found
The kindergarteners from child care centers
who had participated in Smart Start quality
improvement activities were significantly
more likely to have a regular source of
health care than children who had not.
Ninety percent ( 90%) of Smart Start
children had a regular source of health
care compared with 82% of non- Smart
Start children. Conversely, 18% of
non- Smart Start children had no
source of regular care compared
to 10% of Smart Start children.
The positive effect of Smart Start child care
on having a regular health care provider
did not differ between white and African
American preschoolers, or between poor
and non- poor children.
Implications and Future Directions
The results show that increased access to regular health care
for children is associated with attendance at child care centers
that participate in Smart Start quality improvement activities.
These activities were not intended directly to affect access to
health services, but it appears that they did or that they are
associated with activities that we did not measure that have an
effect on health services. However it is achieved, any reduction in
use of emergency room care represents a significant cost savings.
Typically, an emergency room visit for a Medicaid- eligible child
with acute otitis media costs $ 41.50, compared with $ 35.52
for an office visit. 1
These preliminary findings of regular access to health care for
children attending centers involved in Smart Start are encouraging.
We are currently completing a larger study focused specifically on
children who participated in Smart Start health interventions.
With more children from more counties, we will be able to assess
the effect of Smart Start on immunizations and other measures
of health status outcomes in addition to access to care.
1 Personal Communication, P. Munson ( Division of Medical Assistance) and S. Horton
( Division of Public Health), NCDHHS, Sept. 15, 2000.